04-29-19 Well and Boring Construction Record

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MINNESOTA UNIQUE WELL : WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD Minnesota Sta 'tes,chapter 1031 8 3 9 6 2 3 Hennepin Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 NW NE SWy, 138 „. 4-29-19 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool aDriven ❑Dual Rotary ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ,,,. ❑Other iS St. [L+47g St, Orono 553( DRILLING FLUID WELL WELL HYDROFRACTURED? ❑Yes, to Show exact location of well/ ring in section grid with"X" Sketch map of well/boring location. Bentonite From ft.To ft. Showing property lines, roads,buildings,and direction. USE N Domestic ,r'. ❑Monitoring ❑Heating/Cooling _ 414 ` ❑NoncommunityPWS ❑Environ.Bore Hole ❑Industry/Commercial 1 ❑Community PWS ❑Irrigation ❑Remedial - ---i------- ❑Elevator ❑Dewatering ❑ w E - e_r4,9, CASING MATERIAL❑Steel Drive Shoe? ❑Yes No ❑Threaded ❑Welded HOLE DIAM. --;-----;- F------ � -7. 6- 'h Mile litiglastic ❑ I CASING Diameter Weight Specifications 1 Mile— in.To 129ft. lbs./ft. in.To . in.To ft. lbs./ft, in.To 1 . PROPERTY OWNER'S NAME/COMPANY NAME . • i a{7tl,R1 BOMB in.To ft. lbs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 1360�� Hamel Rd Make From ft. To ft. Medina, MN 55340 Type stainless steeI Diam. Z" Slot/Gauze .010 - Length 41 f 44 Set between 129 ft.and 138 ft. FITTING8rx3. leader STATIC WATER LEVEL 54 ft.," Below ❑Above land surface Date measured 4'29-19 Dry hole ❑Yes liNo ,, WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 120 40 ft.after 2 hrs.pumping g.p.m. Well/boring owner's mailing address if different than properly owner's address indicated above. WELLHEAD COMPLETION ]g Pitless/adapter manufacture odel I�Casing protection 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentOniterom 0 To 50 ft. 3❑Yds. NeBags Material cuttings. From 50 To .IX ft. ❑Yds. ❑Bags HARDNESS OF Material from To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags = One bag94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION . � clay b 0 17 Well is 045.--° feet direction from c`,"�' type Off Well disinfected upon completion? ;gl'es ❑No Clay .gray �u1 9017 90 PUMP > /9 — sand/gravel mi% soft 112 ❑Not installed Date installed ( /" I5— Manufacturer's name rig—sand brown soft 112 124 Model Number [�j u HP ,/dam- Volts �O - --- Length of drop pipe O I ft. Capacity g.p.m sand brown soft 124 138 Type:` e'ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ — ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes.No VARIANCE Was a variance granted from the MOH for this well? ❑Yes, .No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. The information contained in this report.is true to the best of my knowledge. Use a second sheet,if needed. . -, REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co,. Inc. 1691 • Licensee Business Name Lic.or Reg.No. r /�,/' ,1/- / 9- /9 —‘(/:, ' Re•res'nt.,i -Signature Certified Rep.No. Date LOCAL COPY 8 3 9 6 2 3 Name of Driller A tY —2±.---Erd-g--4-19'....... ID#52603 HE-01205-17(Rev.5/17)